Medicine Flashcards
1
Q
How do you manage the patient with DKA?
A
Admission to step-up or ICU
Frequent vitals and neuro assessment
Frequent venous blood glucose, lytes, pH, anion gap, creatinine, osmolality q2h
Assess & treat precipitating illness
2
Q
What are the 3 pillars of DKA management?
A
IV fluids
Serum K+
Acidosis
3
Q
What are the most common precipitating factors for DKA or HHS?
A
Inadequate insulin therapy or infection
Other factors: MI, PE, cerebrovascular accident, pancreatitis, certain meds (e.g. SGLT inhibitors), alcohol/drug use
4
Q
What is the management of fluids in the treatment of DKA?
A
is pt in shock, severe dehydration? then NS 1L/h, otherwise 500 mL/h x4h, then 250mL/hr.
Once euvolemic, assess corrected [Na+], use 1/2NS if high/normal, add D5 to keep glucose around 14)
5
Q
How do you manage serum K+ in the setting of DKA?
A
If K+ < 3.3 mmol/L, correct hypoK+. before giving insulin (max 40mmol/L KCL). Otherwise, run less.
6
Q
How do you manage acidosis in the setting of DKA?
A
If K+>3.3, administer IV insulin 0.1 U/kg/h. If pH <7, give bicarb. Continue to administer insulin until anion gap closes (+dextrose if need be)
7
Q
How do you correct Na+ for blood glucose?
A
Corrected = [Na+] + 3/10 (BG -5)
8
Q
What are the long-term complications of diabetes?
A
Microvascular: retinopathy, nephropathy, neuropathy
Macrovascular: CAD/CVD/PVD
other: cataracts, MSK/skin changes, foot infections, sexual dysfunction etc.
9
Q
How would you differentiate between HHS and DKA?
A
HHS - bicarb normal, BG +++++ higher than DKA, plasma Osm >320 mosm/kg. More likely to present type 2 and older and also with ALOC or confusion. Longer course of illness developing over days-weeks.
10
Q
Is T1DM or T2DM more likely hereditary?
A
T2
11
Q
How do you manage HHS?
A
Focus on fluids, be careful to not cause cerebral edema, don’t correct osm by more than 3 mosm/kg/hr. Use 0.1U/kg/hr insulin, use 1/2NS if corrected Na+ > 135.
12
Q
What are the key criteria for determining that a CXR is “good”
A
non-rotated (spinous process centered between clavicles), adequate inflation (6-8 anterior ribs, 10-12 posterior ribs), exposure (vertebral body visible)
13
Q
What are important considerations when ordering CT?
A
Watch for contraindications to contrast (renal disease, contrast allergy, able to consent).
Make sure you specify what are you looking for.
14
Q
What is the diagnosis?
A
Left upper lobe consolidation, likely pneumonia
15
Q
Where is the pneumonia?
A
Right lower lobe
Note that spine sign, the lungs should become darker towards the bases
16
Q
Where is the pneumonia? What is the sign?
A
RML pneumonia (silhouette sign present). On the lateral, the consolidation is anterior
17
Q
Where is the pneumonia?
A
Right upper lobe
18
Q
Where is the pneumonia?
A
Left upper lobe (notice it is anterior to the fissure in the lingula
19
Q
Where is the pneumonia?
A
Left upper lobe (again, anterior to the fissure)
20
Q
What is the diagnosis (35yo homeless, presenting with coughing and hemoptysis)
A
Notice cavitations in the upper lungs (lucency in the lungs) - TB
21
Q
What type of TB is this?
A
Miliary TB - hematogenous spread
22
Q
What is the diagnosis in this person with chest pain? What is the next step?
A
Worried about aortic dissection
Most commonly CT with contrast
23
Q
How are aortic dissections classified?
A
A -> Ascending aorta (surgical)
B -> descending aorta, distal to L subclavian
24
Q
Preop CXR, what is the finding? What is the differential? What is the next step?
A
Infection, lung cancer, benign module?
Try to compare with previous (if >2 year likely stable)
or CT -> if suspect malignancy, then refer!
25
What is the diagnosis?
PE (saddle embolus)
26
What is the diagnosis?
Paratracheal and mediastinal hilar adenopathy - most likely sarcoidosis since bilateral, but need to rule out atypical infection and malignancy
27
55M PMHx significant for previous cardiac disease presenting with SOB
CHF / pulmonary edema
Notice, septal lines, Kerly B (horizontal lines going all the way out to the lung periphery), peribronchial cuffing, air bronchogram)
28
What is the finding?
Right paratracheal lymphadenopathy
29
What is the finding?
right middle lobe nodule
30
What is the finding?
Rib fracture (right upper lobe) notice subcutaneous emphysema
31
What is the finding?
Right upper lobe pneumonia
32
What is the diagnosis?
Left pneumothorax
33
Is alcohol a risk factor for heart failure?
Yes! esp if there are no other risk factors + heavy alcohol consumption
34
How is heart failure defined?
A clinical syndrome resulting from cardiac decompensation characterized by volume overload +/- inadequate tissue perfusion.
35
How do you classify heart failure?
HF with reduced ejection fraction (EF <=40)
HF with preserved ejection fraction (EF >= 50)
"borderline" if (EF 41-49)
improved (with recovered EF >40)
36
How do you differentiate between left and right-sided HF
left-sided -> classic SOB, orthopnea, palpitations fatigue
right sided -> tends to be lower limb edema, abdominal distension etc.
37
How do you ask about heart failure symptoms?
Ask about what level of exertion gets you tired rather than asking specifically about C/P or dyspnea
38
What are the signs of heart failure
increased JVP,
S3 gallop,
etc.
39
What is the, initial workup for suspected HF?
CXR, ECG, BNP, CBC, lytes, Cr, U/A, glucose, thyroid
echo
40
What causes the S3 gallop?
blood rushing in from the left atrium due to congestion / high atrial pressure.
41
How do you evaluate functional capacity in the patient with suspected HF?
NYHA classification
I - no symptoms
II - symptoms with ordinary activity
III - symptoms with less than ordinary activity
IV - symptoms at rest or with any minimal activity
42
How do you manage what are non-medical interventions in HF?
Lifestyle modification: stop smoking and EtOH, avoid obesity, salt & fluid restriction, exercise
Manage HTN, intravascular or valvular disease, arrhythmias, OSA, anemia
43
What medications should be avoided in the setting of HF?
Avoid NSAIDs, CCBs (verapamil, diltiazem), glitazones
44
What medical therapy is useful for heart failure?
45
What are the standard initial therapies for HFrEF?
ACEi/ARB or ARNI + beta blocker, MRA (e.g. spironolactone), SGLT2 inhibitor. Treat any comorbidities, may need additional diuretics to maintain euvolemia
46
What is the target dose of bisoprolol in an HF patient?
10 mg daily
47
What drug does NOT improve survival in HF?
Digoxin - reduces hospitalization, but doesn't improve survival
48
When do you consider cardiac resynchronization therapy?
If they are symptomatic LVEF <30 w LBBB in sinus rhythm - put in a pacemaker into the coronary sinus.
49
When do you do ICD?
If patients have low EF <30% despite optimal medical therapy.
50
What are indications for cardiac transplant?
```
Advanced (class III / IV), poor prognosis despite optimal medical and electrical device therapy.
No contraindications (e.g. infection, severe PVD or cerebrovascular disease, alcohol, drug use, VTE, fixed, high pulmonary vascular resistance, systemic multiorgan ilness)
```
51
What are the common causes of acute HF?
Medication non-adherence, ACS, infections
+++HTN -> diastolic dysfunction due to ischemia, worsened by tachycardia.
52
How do you classify acute heart failure?
(most common) Wet and warm (adequate perfusion, congestion -> diuretics +/- nitroglycerin)
Wet and cold (inadequate perfusion -> diuretics + inotropes)
Dry and cold (fluids)
53
How do you diagnose HFpEF?
Normal EF and LV volume, but with LVH, left atrial enlargement and/or other abnormalities on doppler echo
54
How do you manage HFpEF?
Diuretics to relieve SOB and edema, manage hypertension, treat any myocardial ischemia.
55
How do you define asthma?
Reversible (w/ bronchodilator) obstruction i.e. FEV1 improves by 200mL+ AND 12%
or
+ve methacholine or exercise challenge.
56
What are the important elements to ask about on history when you suspect asthma?
```
Triggers
associated conditions e.g. eczema or nasal polyp
Smoking history
What features: cough, dyspnea
Exposures (occ hx, pets)
FH
```
57
What are the criteria that define good asthma control?
Daytime symptoms < 2 days a week, reliever < 2 doses / week
Nighttime symptoms < 1 night/week, mild
No restriction in physical activity or absence from work or school. Mild & infrequent exacerbation
PEF >90% of personal best, consistent FEV1 (<10-15% variation within the day)
Sputum eosinophils < 2-3%
58
How do we treat asthma?
Confirm diagnosis + provide education & a written plan
Prescribe PRN SABA or budesonide / formoterol (LABA)
Start with inhaled corticosteroid and titrate up +/- montelukast
+LABA if >12yrs
+tiotropium
59
What do you think about in difficult to control asthma?
Review medical adherence + lung association video for technique
Trigger avoidance
Consider allergic bronchopulmonary aspergillosis or eosinophilic granulomatous polyangiitis
Consider comorbs: PND, GERD, allergies
60
What are some asthma mimics?
Consider asthma mimics: COPD, bronchiectasis, vocal cord dysfunction, upper airway obstruction, cardiac disease, sarcoid, hypersensitivity or OSA
61
What is the workup for difficult to control asthma?
PFTs + maximal inspiratory curve
CBC, IgE, ANCA
Allergy test
CXR, CT sinuses, CT thorax
62
Identify the type of obstruction
A. fixed obstruction e.g. tumor
b. variable extrathoracic obstruction (normal exhalation)
c. variable intrathoracic obstruction (normal inhalation)
63
What are worrisome signs on physical exam?
Resp. distress, hypoxia, accessory muscle use, pulsus paradoxus, quiet chest, fatigue, decreased LOC, hyperinflation.
64
How do peak flows help with disposition?
If >60%, probably ok for discharge
| < 25% requires admission
65
How do you define COPD?
Nonreversible airway obstruction (FEV1/FVC <70%)
66
What is the cause of COPD?
Mostly smoking or smoke exposure
67
What do you want to ask abou t
Smoking hx, cough, functional capacity (MRC dyspnea)
Sputum
Exacerbations - how many, admission / ICU, requiring ventilation?
Rule out comorbs: HF, anemia, deconditioning, asthma
68
What do you want to look for on physical exam
Look general inspection (pink puffer / blue bloater)
Clubbing - this isn't a feature of COPD
Cyanosis
increased WOB, tripoding
Chest shape
Auscultate (wheeze, quiet, prolonged exp. phase)
69
What investigations are indicated in COPD?
PFTs
6-minute walk test
CXR
CT if you are r/o something else (e.g. smoking CT screen)
70
What is the non-phrarm management for COPD?
Smoking cessation, exercise / rehab, influenza and pneumococcal, COVID vaccine, oxygen if needed
71
What is the pharmacological management of COPD
Short acting bronchodilator PRN
+ long acting therapy (LAMA +/- LABA +/- ICS if frequent exacerbators)
+ oral therapy (+/- PDE-4 inhibitor, macrolide (azithromycin / erythromycin, mucolytic)
+ long-term oxygen +/- noninvasive ventilation
+ lung transplant
72
How is COPD exacerbation defined?
A sustained worsening of the patient's condition beyond normal day-to-day variation acute in onset requiring a change in regular medications
73
How do you manage acute exacerbation of COPD?
Target O2 to 88-92%
Inhalers (ventolin + ipatropium q15 minutes)
Systemic steroids
Antibiotics if purulent
74
What are your most common pathogens that cause AECOPD?
H flu, Moraxella catarrhalis, Strep pneumo
75
What is the cause of dyspnea?
Mismatch between ventilatory drive and respiratory mechanics
76
How do you workup the patient with dyspnea?
Get Hx of infection, medication compliance, c/p cough
Vitals, physical exam
ECG, CXR
CBC + stufff
77
What are nonpharmacologic management of dyspnea?
Neurostim, chest wall vibrations, walking aids, pursed lip breathing
78
What pharmacologic management helps with dyspnea? What medications should you avoid?
Opioid, anxiolytic (unless they have anxiety), antidepressants
79
What is the DDx of chest pain?
Can't miss: ACS, aortic dissection, tamponade, PE, PTx or esophageal rupture/impaction
Think of anatomy: MSK (costochondritis, #), Skin (Zoster), nervous (radiculopathy), GI (reflux, ulcer), cardiac (HF, valve stenosis), lung (pneumonia, diaphragmatic hernia), mediastinum (fat necrosis)
80
What is the difference in pathogenesis between stable angina and ACS?
ACS ruptured plaque -> +++thrombogenic material creates a thrombus, nonocclusive or occlusive (full STEMI)
in stable angina, we have progressive obstruction.
81
How do you manage stable angina?
Single antiplatelet therapy (aspirin) + statin
82
How do you manage unstable coronary syndrome?
Dual antiplatelet therapy (aspirin 160mg loading then 81 daily + (P2Y12inhibitor) ticagrelor 300 loading 75 daily or clopidogrel 180 loading + 90 BID)
Anticoagulation (heparin, DOAC (dabigatran), NOAC or warfarin)
Statin
O2 to 90%
83
What is the expected rise in Hb following 1U RBC transfusion?
10g/L
84
At what level of Hgb do you consider transfusion?
<70 or <80 if preexisting cardiovascular disease
as long as they are hemodynamically stable.
85
What are the most common transfusion reactions?
fever / hives, can stop the transfusion and give tylenol +/- benedryl
86
What bugs are you thinking in the febrile 17 yo M with nuchal rigidity?
```
Acute meningitis - most concerned about bacterial causes
#1 Strep pneumo (gram +ve cocci in pairs/chains)
Neisseria meningiditis (gram negative think about shared dwellings)
H flu (gram negative)
```
if they are older, pregnant, EtOH or immunocompromise don't forget about Listeria monocytogenes
87
What pattern of changes do you expect on LP for bacterial meningitis?
CSF showing increased protein, low glucose and ++PMNs.
88
What is empiric therapy for acute bacterial meningitis?
Ceftriaxone 2g IV q12h (4x usual dose for CSF)
Treat for 10-14 days if strep, listeria, 7 days if other
Vancomycin 1-2g IV q12h as adjunct to resistant Strep pneumo
+ampicillin 2g IV q4h if concerned about Listeria. (or septra if penicillin allergy)
+acyclovir if you think it's viral
89
What is adjunctive therapy in addition to empiric antibiotics for acute bacterial meningitis? When do you give it?
Dexamethaosne 10mg IV q6h x4days. Give with 1st dose of Abx, do not wait for CT scan or LP
90
What is your differential in the 30yo with flank pain, dysuria and new onset hematuria?
Can be cystitis, pyelonephritis
STI, Vaginitis
Nephrolithiasis
Other...
91
What is the microbiology of UTI?
E coli in 80% of cases
| KEEPS: Klebsiella, Enterococcus, Proteus, Staph saprophyticus
92
What are helpful investigations for diagnosing UTI?
Clinical syndrome
U/A (dipstick, micro)
Urine and blood Cx
Smell / appearance of urine not reliable for diagnosis
93
What are helpful investigations for diagnosing UTI?
Clinical syndrome
U/A (dipstick, micro)
Urine and blood Cx
Smell / appearance of urine not reliable for diagnosis
94
When do you not do a urine Cx
Don't do urine Cx in the absence of symptoms or post-treatment.
95
When do you treat asymptomatic bacteriuria?
Pregnancy or invasive urological procedures.
96
What differentiates uncomplicated cystitis?
Young, premenopausal and nonpregnant, otherwise-healthy, women who present with classic symptoms and w/o recurrent disease.
97
What is the treatment for uncomplicated cystitis?
Abx 3 day of either
nitrofurantoin (100mg BID)
or
TMP-SMX
98
What is usual therapy for complicated cystitis or pyelo?
7-14d of TMP-SMX
7d fluoroquinolone
10-14 days of clav
99
What are inpatient options for pyelo?
7 days initially IV ceftriaxone, gentamicin, fluoroquinolone ( +/- amp for enterococcus) with step down PO
100
63F fever and swelling/erythema over left leg skin. What is your differential?
```
Erysipelas
Cellulitis
Deep tissue infection
Drug eruption
DVT, venostasis, lymphedema
Malignancy or radiation rxn.
```
101
What is the microbiology of cellulitis?
Nonpurulent is Group A Strep / Strep pyogenes
Pus = Staph aureus (could be MRSA)
102
Nonpurulent cellulitis - what's the treatment?
Cephalexin 500mg PO QID
Cefazolin 1-2g IV q8h
for 5-7 days.
Counsel patients that redness and swelling will persist after bacteria are dead.
103
What if you have purulent cellulitis?
I/D, send aspirate for C/S. May not require antibiotics.
| You may add 1st gen cephalosporin for 5-7 days.
104
How do you approach the non-resolving cellulitis?
Potential drug/bug mismatch, could be wrong diagnosis?
105
What exposure hx do you want to ask on screening for atypical cellulitis?
Salt water exposure, cultured fish, shellfish/meat (butcher)/hides, bites (pets, human)
106
73M hx of diabetes non-healing ulcer on left foot for months. What is the most likely cause? What should you do on exam?
```
Gram positives (S. aureus, strep)
Enterobacter / pseudomonas / anaerobes (less likely)
Do not do superficial swab
Look for symptoms of infection
Don't discount lack of pain.
X-ray for osteomyelitis
```
107
Empiric antimicrobial for diabetic foot ulcer?
1st gen ceph 5-7days if surface
| If severe or chronic (ceftriaxone 1g IV qd + metronidazole 500 mg BID) or Pip-tazo + vanco
108
55F profuse watery diarrhea, breast cancer in remission, lymphedema + recurrent cellulitis of L arm.
What should you ask on hx?
Characterize stool. Blood or not? Ask about associated symptoms? Prior episodes and causes if known? Travel / exposure. Meds/drugs. FH (IBD?).
109
What is your workup for diarrhea?
Assess severity (serum electrolytes, clinical status)
Stool C+S
Stool O&P (make sure it's in the right media, but probably not if immunocompetent)
C. diff testing.
If febrile, consider blood cultures, stool AFB or endoscopy
110
How do you manage diarrhea?
Isolate pt (contact), provide supportive care, don't give antimicrobials.
Stop medications if they are contributing.
111
How do you treat C. diff?
Vancomycin PO x10-14days or give metronidazole PO
| If severe + metronidazole IV
112
What is the workup for pneumonia
```
CXR +/- CT chest
CBC, creatinine
Sputum or blood cultures (if concern for resistance or ill)
Can look for Legionella Ag in urine
Sputum AFB for TB
NP swab COVID
```
113
What is atypical vs typical pneumonia in terms of bugs?
S pneumo and H flu are typical (also think staph aureus, group A strep moraxella). Lobar pneumonia.
Atypical (think Legionella, Mycoplasma, Chlamydia). Appearance tends to be patchy infiltrates.
114
If you have apical pneumonia, what must you consider?
TB
115
If you have diffuse, streaky interstitial pneumonia in the patient that is immunocompromised, what do you think of?
Pneumocystis pneumonia
116
When do you cover atypicals?
Definitely if they are in ICU, maybe if they are inpatient, probably not if they are outpatient.
117
What is empiric therapy for pneumonia
Ceftriaxone +/- azithromycin
Amoxicillin-clavulanate +/- azithromycin.
if you want atypical coverage, levofloxacin or moxifloxacin
Can stop if they feel better after 5 days.
118
What is the scoring system to determine if someone should be admitted for pneumonia?
```
CURB-65
2+ should admit 3+ consider ICU
Confusion
Urea >7
RR > 30
BP >90/60
Age > 65
```
119
How do you monitor response to antimicrobial therapy in pneumonia?
Improved resp. status / vitals, no need to repeat X-ray to check for improvement.
120
What are the 5 causes of non-resolving infection?
```
Drug-bug mismatch
Drug can't get to bug
Complication of infection
Wrong diagnosis
Impatient clinician
```
121
What are the likelihood of blood transmitted infection?
<1 in 1 million (1 in 7,600,000)
122
What are the other serious risks to remember in transfusion?
TACO and TRALI
123
What is the difference between an antibody screen and a crossmatch?
Antibody screen -> plasma is screened for antibodies to test red cells.
Cross-match, we mix recipient plasma with red cells from donor.
124
How do you prevent TACO?
transfuse one unit at a time over 3.5 hours and add lasix for patients >60 and/or with history of CHF
125
What is TRALI?
Transfusion-associated acute lung injury
New onset or within 6 hrs of transfusion, new acute lung injury with bilateral infiltrates on CXR w/o evidence of fluid overload.
126
How do you manage TRALI
Let lab know (need to quarantine other products)
| Supportive care
127
When should you order platelets?
Typically < 10 x 10^9/L for spontaneous bleeding
<50 for major bleeding / procedures
<100 Or neurosurgery or eye surgery
1-> why does the pt have a low platelet count? (consider contraindications to platelet transfusion e.g. TTP, heparin-induced thrombocytopenia)
2->are they bleeding? (typically mucosal bleeding)
3->do they have a procedure coming up?
128
How much Plt will increase after 1 adult platelet unit?
15-50 x 10^9
129
When do we transfuse plasma?
Major bleeding with INR > 1.8, massive microvascular bleed / MTP.
Remember the 1/2 life is 6-8 hrs.
Multiple clotting factor deficiencies where a product that is mores specific isn't available.
130
What is the cause of an elevated PTT in isolation?
Heparin, lupus, severe VwD or single factor 8,9, 11 or 12 deficiency
131
What is the cause of elevated INR in isolation?
Liver disease, warfarin, vitamin K deficiency or single factor deficiency of factor 7
132
What can cause both INR and PTT to be elevated?
DIC, liver disease, vitamin K+ deficiency / warfarin, high dose heparin, anticoagulation, single factor deficiency of 10, 5, 2 or 1
133
What do you use to reverse warfarin emergently?
PCCs
134
What is the diagnostic criteria for diabetes?
Fasting BG > 126 or 7 mM, with repeat testing
Random glucose >200 or 11.1 mM that is symptomatic
OGTT with >200 or 11.1 following 75g gluc load 2hrs and repeated on a different day
A1C> 6.5
135
What are the 3 criteria of diabetic ulcer that is suspicious for osteomyelitis.
2cmx2cm
Probe to bone
Esr >70
136
What is the course of therapy for osteomyelitis?
6 weeks IV
137
Sputum samples, what is the best time to collect?
First morning sputum
138
What disease should you also check if someone has a new TB diagnosis?
HIV
139
What screening is needed for household close contacts of a new TB DIAGNOSIS?
Skin test
140
What investigations are needed before starting treatment for TB?
CBC, lytes, Cr. LFTs ophthalmology for Ethambutol.
Isolate min 2 wks.
Notify public health
141
What are the drugs for active tb? What side effects do you worry about?
Rifampine, isoniazid, pyrazinamide, ethambutol
Rifampine, warn pt about pee
Isoniazid - LFTs follow and supplement with B6
Ethambutol colour vision change
142
What is the treatment for latent TB
Rifampin for 4 months
143
What is the cutoff for induration for TB skin test?
5mm if special cases at high risk eg HIV, contact, ESRD, +Ve CXR, Immunosuppressed
10 for everyone else
144
What tests should be performed for the initial workup of febrile neutropenia?
Blood cultures (draw from central + peripheral if both present). CBC, lytes, liver tests.
145
What is the definition of AKI
26,5 mmol rise in cr over 48hr
1.5x baseline within 7 days
Urine volume <0.5mL/Kg/hr x 6hr
146
Ddx for pre-renal AKI
Hypovolemia
Third spacing or bleed
Drugs: ACE/ARB, NSAIDs (AIN), contrast agents (ATN), Lasix, thiazides, Septra, aminoglycosides, amphotericin B.
Renal artery stenosis including hypercalcemia
147
What renal meds cause issues
Lithium, tenofovir
148
Post renal ddx
Obstruction risk factors urinary symptoms, recurrent uti, renal colic, prostate issues, long-standing DM, etc.
149
Intrinsic renal disease what are the causes
Glomerular (nephrotic vs nephritic), tubular (drugs), vascular (thrombotic microangiopathic disease TTP / HUS, vasculitides, lupus, polyarteritis nodosa) , interstitial (idiopathic vs secondary (MM, lupus, sarcoidosis) vs meds)
150
What are some classic syndromes of interstitial disease
2month Hx if fatigue or B symptoms from previously healthy, hématurie and protéinuria and worsening kidney function.
151
If you get staph aureus back, is it ever a contaminant?
No. You must treat it.
152
What are the risk factors for staph aureus bacteremia?
IVDU, Central lines, Prosthetics, Surgery, Diabetes, Immune suppression.
153
When do you need to repeat blood cultures for staph aureus?
2-4 hrs post.
154
What are the signs of complicated staph aureus
Endocarditis, positive f/u blood culture post abx, osteomyelinitis, metastastic infection
155
What is the workup for staph aureus bacteremia
Repeat blood cx
Echo , TEE if intracardiac,
ID consult, source control
Abx, empiric with vanco or dual therapy if septic shock or IE
Definitive is cefazolin 2g IV q8h, cloxacillin 2g IV q4h
Vanco if MRSA, if hardware then rifampin, aminoglycosides
156
What is the danger of hypernatremia?
Acutely, this causes brain cell shrinkage; chronically the brain adapts by increasing its intracellular osmolarity; overly rapid correction can lead to demyelination and/or cerebral edema.
157
What is a safe rate of correction for hypernatremia?
6-8 mmol/L/day
158
What is "free water"
The volume of solution that can be removed, leaving behind an isotonic solution
159
How do you approach polyuria?
Either - you are losing sodium and have concentrated urine OR you have water diuresis (dilute urine)
160
What are the causes of solute diuresis? (high Urine osm, but LOW Na)
Glucose (DM), Urea (often due to excessive NG/G tube feeding), NaCl (loop diuretic, salt-wasting nephropathy)
161
How do you distinguish between central and nephrogenic DI?
Give patient ddAVP and see if they concentrate the urine. If they do, then it's central DI, if they don't then it is nephrogenic DI (bc they are resistant)
162
How do you manage hypernatremia?
Give free water: PO or IV; D5W, 2/3 & 1/3, 1/2 NS. Goal is 1.5 cc/kg/hr of free water. BUT keep in mind they may also have a sodium deficit. That's why 1/2NS is good. Monitor, treat underlying cause & replace additional losses.
163
What is the danger of hyponatremia?
Acutely - cerebral edema; the danger is that we do not want to correct too quickly because that can cause the cells to shrink and demyelinate
164
How do you correct plasma Na+ for glucose?
add 4 for each 10mmol of glucose rise
165
How do you know if hyponatremia is truly a problem?
Check the serum osm! if it is not low, then you have something else suppressing the Na+
166
How do you approach the diagnosis of hyponatremia?
Excessive intake (e.g. psychogenic polydipsia)
OR
Why is there ADH when there shouldn't be?
Either:
1) SIADH (ectopic, CNS/lung disease, drugs (SSRIs, MDMA), hormone deficiency (cortisol/T4), stress)
2) True hypovolemia (hemorrhage, GI losses, diuresis, skin loss, third-spacing)
3) Hypervolemia but with arterial volume depletion (HF, cirrhosis)
167
How do you manage hyponatremia with seizure?
Attend to ABCs, give IV benzos, 3% NS (150mL bolus) and continue to 5mmol increase)
168
How do you manage chronic hyponatremia?
Moderate symptoms (confusion, nausea, vomiting)
Acute hyponatremia -> 3% NaCl
Otherwise, treat the cause
Is Na<120 and or at risk of dilute polyuria -> give DDAVP
169
What are the contraindications to LP?
Bleeding problems - uncorrected coagulopathy, low platelet (<40), antithrombotic therapy (DOAC, heparin, LMWH, Clopidogrel / Ticagrelor)
Risk of brain herniation (increased ICP),
170
Where do you send the fluid?
4 Cs
Chemistry
Cells: micro / cytology
Crystals
171
How do you differentiate between bacterial and viral meningitis?
WBCs +++ PMNs (>10^9) = bacterial
LOW glucose = bacterial
HIGH protein = bacterial (>1g/L) there's schmuck
172
How do you distinguish transudative vs exudative ascites ?
SAAG = serum - ascites albumin
If >11 = transudate (likely cirrhosis, CHF)
If <11 = exudate (cancer, inflammation, TB -> capillary damage).
173
When d you suspect SBP?
if paracentesis is transudative ascites AND PMNs > 250 x10^6
174
What are light's criteria for pleural infusion?
LDH pleural fluid : serum < 0.6
AND
Total protein pleural fluid : serum < 0.5
AND
LDH pleural fluid < 2/3 upper limit of normal for serum
175
What produces an exudative pleural effusion? Transudate?
Exudate: Cancer, infection, PE
| Transudate = CHF
176
What are the causes of an unconjugated hyperbilirubinemia
Non liver: lysis of red cells (hemolytic anemia or drugs e.g. sulfa, nitrofurantoin, ribavirin) or bleeding into a cavity -> hematoma
Liver: decreased uptake (rifampin or CHF), decreased conjugation (gilbert, Crigler-Najjar, Estrogen)
177
What are the causes of decreased excretion of bilirubin conjugates?
Decreased excretion of conjugates (Dubin-Johnson, Rotor, Hereditary Cholestasis)
178
What are the causes of hepatocellular damage leading to conjugated hyperbilirubinemia?
Hepatocellular damage (Viral hepatitis, alcoholic liver disease, drugs (acetaminophen, INH, stasis), sepsis
179
What can cause intrahepatic cholestasis?
Intrahepatic cholestasis: infections (cancer, infections, sarcoid, TB / granulomatous disease), drugs (OCP amox/clav)
180
What can cause biliary obstruction?
Obstruction: Gallstones, bile duct carcinoma, sclerosing cholangitis, pancreatitis, extrahepatic tumors.
181
What is the classification of acute liver failure?
Fulminant (<8wks previously healthy), Subfulminant (<26wks previously healthy)
182
What are the clinical parameters of acute liver failure?
Confusion, jaundice, GI bleed, ascites
183
What are the biochemical signs of acute liver failure?
Increased INR, Bili Cr
| Decreased Albumin Glu
184
What 5 conditions that cause an ALT/AST >1000
infection: viral hepatitis (A / B acute)
autoimmune: autoimmune hepatitis (classically in pregnancy)
vascular: Budd-Chiari - thrombosis of the hepatic vein. Diagnosed with doppler U/S
drugs/toxins: acetaminophen -> give N-acetyl cysteine
acute biliary obstruction: often gallstone
185
What is the relevant ROS of Jaundice?
B symptoms (cancer)
Joint pain/ Swelling (autoimmune)
Wilson disease (psych symptoms, kayser fleischer ring, hemolytic anemia)
Hemochromatosis (bronze skin + diabetes)
Alpha-1-antitrypsin deficiency (lung problems)
Sicca syndrome: Itchy dry eyes or mouth (PSC / PBC)
Missed menses (cirrhosis)
186
How is the hepatocellular pattern different than cholestasis biochemically?
Hepatocellular: AST/ALT > 500 u/L, ALP < 3x Upper Limit of Normal
Cholestasis: ALP+++ >3x limit of normal
187
What causes ALT 200-500?
```
Alcoholic liver disease
NASH
Viral hepatitis (chronic)
Wilson disease
Hemochromatosis
```
188
Why doesn't AST / ALT increase as much in an acute on chronic insult to the liver? What is the W of cirrhosis?
```
Bc there's just less liver cells to break down.
Initially - things are normal
1) Low platelets
2) INR goes up
3) Albumin goes down (ascites)
4) Bilirubin goes up (encephalopathy)
```
189
What are the complications of liver cirrhosis?
```
Ascites -> Hepatic hydrothorax
SBP
Hepatorenal syndrome & Hepatopulmonary syndrome
Variceal hemorrhage
Loss of synthetic function
Portal HTN
Hepatic encephalopathy
HCC
etc.
```
190
How does ascites predict survival?
2 year survival is 50%.
191
How do you prognosticate liver disease with the child-pugh classification?
```
A = 5-6, 100% 1 yr survival
B = 7-9, 80% 1 year survival
C = 10-15 45% 1 year survival
```
192
How do you manage cirrhosis?
```
Treat underlying cause
Vaccinate HAV/HBV
Abstain from alcohol
Screening endoscopy (if plt < 100)
U/S for liver cancer
```
193
How does UGIB present?
hematemesis or coffee ground emesis
Melena
Hematochezia (with brisk UGIB or local LGIB)
Iron deficiency anemia
194
How do you differentiate melena from constipation?
Melena will turn the toilet paper black (not green or brown)
195
What are the most important features of the physical exam for the acute GIB?
Vitals + postural vitals; ABCs
Look for icterus, pallor, lympadenopathy, tealgiectasia
Abdo -> ascites, distended abdo wall veins, masses
DRE
196
What do you do if you have an acute UGIB and you're worried about variceal bleed?
```
Stabilize, Cross/type
NS bolus
Monitor U/O with foley
Correct coagulopathy
Call ICU
Call gastroenterology
```
```
IV pantoprazole infusion (80mg bolus, 8mg/hr)
IV octreotide
IV ceftriaxone
Albumin -> helps it stay intravascular
Intubation if needed to protect airway
```
197
What are the labs for acute GIB?
```
CBC pre/post
BUN
Cr
INR
LFTs
```
198
What red flag symptoms do you worry about in the outpatient setting?
```
New onset symptoms with age > 50
FH
New onset abdo pain
Nocturnal diarrhea
Rectal bleeding, melena
Unexplained iron deficiency
Abdo mass
B symptoms
```
199
How do you send tests for celiac disease testing?
IgA + IgG level (otherwise if low false negative)
| tTG
200
How do you work up a PUD that is hemodynamically significant?
Stabilize, ABCs, urgent scope
201
What are the causes of PUD?
NSAIDs or H pylori.
202
What methods can be used to test for h pylori?
Serology (if they've never been exposed, doesn't tell you if active)
Biopsy
Urea breath test.
203
What is the therapy for H pylori?
Quadruple therapy: PPI, tetracycline, metronidazole, bismuth.
204
What are the complications of H pylori infection.
Gastritis, gastric atrophy, ulcer, MALT lympoma, gastric cancer
205
What is the Ddx for LGIB?
BRBPR acute: diverticular bleed, ischemia (pain then blood), angiodysplasia, inflammation, hemorrhoid
Anemia +/- BRBPR, melena ->tumor!!
206
What are the screening tests for colon cancer?
FIT test (fetal immunohistochemistry test) detects blood in stool q2y between 50-74 if no colonoscopy in last 10 yrs
Unless if family history of colon cancer / polyps (or personal history) in which case it goes to...
Flex sig or colonoscopy.
if FIT +ve must have colonoscopy
207
What HIV test should you order if you are worried that someone has HIV?
HIV test = HIV 1&2 antibody + P24 antigen
Rapid HIV POCT = HIV-1 and HIV-2 antibody (but can be negative if in window last 3 months)
Neonate = HIV DNA PCR (bc they may get antibodies from mom)
208
When after exposure do HIV+ve individuals present with "seroconversion syndrome"?
6 weeks.
209
What do you counsel patients on prevention of transmission?
```
Undetectable virus = untransmissible
HIV prophylaxis
Disclosure - mandatory with all partners
Condom use
Risk of transmission with pregnancy (w/o treatment 25%, w 1%), blood donation, needle stick (67/10000)
```
210
What do you need to do if someone has a new diagnosis of HIV?
Tests: coinfections (e.g. gonorrhea, chlamydia, syphilis, TB, Hepatitis (A,B,C), HPV (annual pap)
Baseline blood work: CBC, Electrolytes, Cr, LFT, Lipids, glucose, urinalysis, beta-hCG
Stage: Confirm diagnosis, viral load, CD4+ count
Testing for drug compatibility: HLA-B570 testing, Tropism (CCR5), G6PD assay
Vaccinations: Annual flu vaccine, prevnar, then pneumovax, Hep A and B, HPV.
211
What are the 4 stages of the HIV life cycle that are targeted by ARVs?
1. Virus Entry
2. Reverse transcription
3. Integration (into genome)
4. Budding & maturation.
212
What are some examples of entry inhibitors for HIV
```
CCR5 antagonists (maraviroc, used for drug resistant HIV)
Enfuvirtide
```
213
What are some examples of NRTIs (backbone x2) for HIV?
Tenofovir (renal, bone side effects), Abacavir (HLA-B5701), Lamivudine, Emtricitabine
214
What are NNRTIs for HIV?
Efavirenz (psychiatric side effects) etc.
215
Integrase inhibitors for HIV?
_ravir
RALtegravir, dolutegravir, elvitegravir, bictegravir
causes dyslipidemia
216
Protease inhibitors (old drugs) for HIV?
_navir
| Need boost + ritonavir, dyslipidemia, cardiovascular disease, drug/drug interactions
217
How is virologic failure for HIV defined? What causes it?
Failure to get under 50 copies /mL on 16-24
Non-adherence, viral resistance, change to drug metabolism.
Better to take a drug holiday or not start rather than promote resistance.
218
At what threshold do you start worrying about opportunistic infections?
```
<200 = PJP, fungi, cryptococcus
<100 = Toxoplasma
<50 = MAC, CMV
```
219
What is primary prophylaxis for PJP & toxoplasma in HIV?
Septra (160/800) or Dapsone 100mg / 200mg (if toxoplasma)
220
What is prophylaxis for MAC with HIV?
Azithromycin 1200mg/day
221
What do you expect in inflammatory vs septic synovial fluid?
Viscosity low -> more likely inflammatory, elevated cells but < 7500
High 50000+ cell count with >75% PMN tends to be septic (and obvs if gram stain / Cx comes back)
222
What is the approach to monoarthritis Ddx?
R/o trauma
Septic until proven otherwise
Crystal arthritis
Hemearthrosis
Less commonly (sickle cell bony crisis, reactive arthritis, lyme, mono-articular flare or osteoarthritis).
223
What types of illnesses can cause pulmonary-renal syndromes?
Infections (most common: stepsis, streptococcal toxic shock, HIV+/- opportunitistic)
Drug/toxin
Autoimmune (Small or medium vessel, SLE)
Autoinflammatory (sarcoidosis, IgG4)
224
How do you classify vasculitis?
Large vessel: temporal arteritis, takayasu's (pulseless disease)
Medium vessel: polyarteritis nodosa, kawasaki (paed's)
Small vessel: ANCA+ve (GPA, eGPA or microscopic polyangiitis (pANCA)), non-ANCA (IgA aka HSP etc.)
225
When should you think about vasculitis?
Pulmonary-renal syndrome (small vessel)
Headache + vision changes esp if older (giant cell arteritis)
Fever + purpura / multisystem involvement w/o infectious cause.
226
What do you need to do if you suspect GCA?
Initial work up to r/o ACS, stroke or intracranial bleed (CT head),
1mg/kg prednisone IV.
In visual loss -> ophtho consult, pulse 1g solumedrol IV for a couple days, then drop to 1mg/kg.
Temporal artery biopsy, image the aorta (echo, MR angiogram etc.)
227
What are the side effects / risks that we need to watch out for when starting high-dose steroids?
Hyperglycemia, acute mental status change (take early in the day), HTN, immunosuppression (very high doses may require PJP prophylaxis), avascular necrosis of the hip, bleeding ulcers (PPI prophylaxis)
228
MCA lesion what is the presetnation?
Contralateral hemiparesis (face/arm > leg)
Contralateral hemisensory impairment
contralateral homonymous hemianopia or quadrantinopia
Eyes deviate towards the side of the stroke (away from the hemiparesis)
229
What features are specific to right MCA stroke
Neglect - anosognosia / asomatognosia or impaired awareness of left
230
What is the key distinguishing feature of left MCA stroke
aphasia
231
What is the difference between FLAIR and DWI
FLAIR shows old strokes and new as white, DWI shows last 7-10 days as white
232
What is the characteristic symptoms of an ACA infarct
Contralateral weakness of leg >> arm
| Contralateral hemisensory impairment in same distribution
233
What is the presentation of PCA stroke?
Contralateral homonymous hemianopia or quadrantinopia
Contralateral sensory impairment
Acute amnestic syndrome (temporal)
Thalamic aphasia (left thalamus)
234
How does a basilar artery stroke present?
```
Trouble speaking swallowing
Double vision, gaze palsy
Vertigo
Contralateral weakness or bilateral weakness
Crossed sensory or motor signs
CN palsy
Ipsilateral or bilateral incoordination
Ataxia
Altered LOC.
```
235
How does a PICA stroke (lateral medullary syndrome) present?
Ipsilateral - facial sensory loss pain/temp, limb ataxia, gait ataxia, nystagmus, N/V, vertigo, hoarseness, dysphagia, Horner's
Contralateral - hemisensory loss of arm/leg/trunk to pain/temp
Scanning dysarthria
236
when do you give tPA? When do you EVT?
<4.5 hours since onset of symptoms or last well.
+/- thrombectomy if large branch occlusion.
Endovascular thrombectomy between 4.5-24 hrs post symptom.
237
What is the absolute contraindication to tPA
Bleeding, ICH, elevated BP (185/110+), INR>1.7 / DOAC wiithin 48 hrs, aPTT increased, low platelet <100,000.
238
What are stroke mimics?
Seizure, migraine, presyncope, psychogenic
239
What is the definition of TIA?
Brief neurological dysfunction <1hr, full recovery no evidence on imaging of stroke.
240
What do you want to do when someone presents with TIA?
Determine cause (MRI ASAP, CT if you can't, CTA and or MRA)
Bloodwork (fasting glucose, lipids, A1C, CBC, Lytes, LFTs, Cr, B12 TSH, hypercoags if FH or prev hx clot)
Address risk factors (HTN, hyperlipidemia, DM, smoking)
Treat extracranial carotid artery disease,
Cardiac exams (ECG, echo, 48hr holter)
241
When should TIA patients get referred for endarterectomy?
>50% stenosis, esp if 70-99% stenosed.
| 100% occlusion is not treated with surgery
242
What is the most common cause of intracellular hemorrhage?
If deep, likely HTN, otherwise amyloid or vascular abnormality
Others: coagulopathy, tumor, CVST
243
What other imaging should you get 2-3 months post-brain bleed?
MRI with gadolinium contrast.
244
What chemo agents can give hematuria
cyclophosphamide / ifosphamide
245
What is the risk factors for neutropenia that warrant staying in hospital?
ANC < 500 / ul
Immune suppression
Foreign bodies (eg. central lines)
246
What is the 1st line therapy for most mass effect oncologic emergencies?
Dex 10mg push then 8mg BID.
247
In what patient population should you avoid doing rectal exams
Febrile neutropenia - want to avoid perirectal abscess
248
What are some triggers for DIC?
Sepsis, motor vehicle accident, acute stressors,
249
What lab signs would you see for DIC?
CBC blood film (schistocytes)
Plt (down)
INR, PTT (up)
Fibrinogen (down)
250
What is the clinical picture for TTP?
```
FATRN
Fever
Anemia (hemolytic)
Thrombocytopenia
Renal disorder
Neurological disorder
```
251
What is the differentiation between TTP and DIC on lab?
TTP does not deplete clotting factors so fibrinogen INR and PTT are normal
252
How do you treat DIC?
Supportive care, fibrinogen, cryoprecipitate, FFP, plt
253
How do you treat TTP?
Plasma exchange (call hematology)
254
How is ITP differentiated from DIC and TTP
Everything is normal except low platelets. Diagnosis or exclusion;
255
ITP treatment?
Prednisone, IVIG, rituximab, splenectomy.
256
How is HIT different from other thrombocytopenia?
Typical onset about a week after starting heparin. PLTs are 100ish, thrombosis
257
What is the 4T score for HIT?
Time
Thrombosis
Thrombocytopenia nadir
AlTernative diagnosis
258
What are the causes of macrocyclic anemia?
B12, thyroid, folate (very rare), pernicious, cirrhosis, alcohol, drugs (MTx, 5-FU)
259
What can cause a normocytic anemia? With high retics
High retics: bleed,
intrinsic: sickle cell, hereditary spherocytosis, G6PD, PNH
Extrinsic: autoimmune hemolytic (hot/cold), MAHA (TTP), HUS (shiga mediated or complement mediated),
Heart valve replacement,
Low retics:
Don’t forget it can be combo of IDA / AICD with e.g. B12
260
What do you send for a hemolytic workup?
LDH, haptoglobin, bili
261
What are the CRAB criteria for multiple myeloma
Hypercalcemia
Renal
Anemia
Bone pain
262
What causes a normocytic anemia with low retics
Myelodysplastic syndrome, malignancy, aplastic anemia, infiltration (bone marrow)
263
What is the appropriate ABx for this organism which was found in urethral discharge from a male
Azithromycin or doxycycline plus ceftriaxone
264
How do you differentiate beta-blocker overdose from opioid overdose?
Beta-blocker = cardiogenic shock
| Opioids tend to be pinpoint pupils, resp depression and resp acidosis
265
In a hypertensive crisis, what guides choice of IV antihypertensives?
If hyperadrenergic eg. Pheo or MAOI Tyramine crisis, need to block alpha then beta receptors. Or use nitroprusside. Otherwise IV labetalol is a good choice and works in pregnancy
266
What is the progression of silicosis?
Either acute (sudden onset respiratory failure, bilateral ground glass opacification, right heart strain or RVF) or chronic, which can be further categorized into simple or massive fibrosis
